Provider Demographics
NPI:1790481521
Name:BUENAVENTURA, MARVIN
Entity Type:Individual
Prefix:
First Name:MARVIN
Middle Name:
Last Name:BUENAVENTURA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:129 E RIDGECREST BLVD
Mailing Address - Street 2:
Mailing Address - City:RIDGECREST
Mailing Address - State:CA
Mailing Address - Zip Code:93555-3918
Mailing Address - Country:US
Mailing Address - Phone:760-463-1613
Mailing Address - Fax:760-463-1614
Practice Address - Street 1:129 E RIDGECREST BLVD
Practice Address - Street 2:
Practice Address - City:RIDGECREST
Practice Address - State:CA
Practice Address - Zip Code:93555-3918
Practice Address - Country:US
Practice Address - Phone:760-463-1613
Practice Address - Fax:760-463-1614
Is Sole Proprietor?:No
Enumeration Date:2023-02-02
Last Update Date:2023-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95023469363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA95023469Medicaid